Medication management in the NSW personal injury schemes: Better practice guide

Introduction

Some medications used to treat injuries sustained at work or on the road have the potential for negative health outcomes, dependence and accidental overdose. This guidance aims to minimise the potential harms associated with the use of medications to support optimal health outcomes for people in the NSW workers compensation (WC) and compulsory third party (CTP) schemes. The guidance includes recommendations and requirements for:

• high risk medications that should be monitored
• the application of the Pharmaceutical Benefits Scheme (PBS)
• indications and use of a medication review
• standardised invoicing requirements for pharmacies.

In this guide, the words ‘must’, ‘required’ (and variations of that word) or ‘mandatory’ indicate a legal requirement that must be complied with. The words ‘should’ or ‘is expected’ indicate recommended best practice.

For guidance on applying SIRA medication codes, refer to SIRA medication codes: guidance for coding.

Medication prescription and supply

Medications in the NSW personal injury schemes:

• must be for the treatment of the person’s compensable injury
• must be prescribed by a legally qualified medical practitioner or dentist registered with Australian Health Practitioner Regulation Agency (AHPRA) under the Health Practitioner Regulation National Law
• must be supplied by a registered pharmacist
• must be prescribed through the Pharmaceutical Benefits Scheme (PBS) where clinically appropriate and available.

1.   High risk medications

These prescription medications have been identified as high risk based on current research evidence. They have the potential for negative health outcomes, dependence and accidental overdose and are the focus of the guidance:

• opioids
• medication-assisted treatment of opioid dependency (MATOD)
• injectable narcotics
• benzodiazepines and z drugs
• medicinal cannabis.

All of these high risk medications are either prescription only (schedule 4), or drugs of addiction (schedule 8). Further information is included in Appendix 1.

Monitoring high risk medication

In line with best practice, it is recommended that insurers monitor the use of high risk medications in the NSW personal injury schemes such as through medication reviews.

2.   Pharmaceutical benefits scheme

The PBS supports the safe and quality use of medications and provides a built-in safety mechanism when dealing with high risk medications.

People receiving their medication related to either a WC or a CTP claim who hold a Medicare card are entitled to access the PBS. The person must present their Medicare card and any concession/entitlement card to the pharmacist.

The prescription and supply of medications in the NSW personal injury schemes must be provided under the PBS where clinically appropriate and available.

Private (non-PBS) prescriptions

A prescriber may provide a private prescription (not through the PBS) when:

• the medication is not available on the PBS, or
• the medication is available on the PBS, but the injured person does not meet the criteria for PBS prescribing, or
• the quantity of medication or number of repeats being prescribed for a medication available through the PBS is outside the PBS prescribing criteria, but can be clinically justified by the prescribing practitioner; or
• in the workers compensation scheme only: pre-approval has been obtained from the insurer to prescribe it privately (after the first month from the date of injury).

If a high-risk medication (e.g., opioids, medication-assisted treatment of opioid dependency, injectable narcotics, benzodiazepines, Z-drugs, or medicinal cannabis) or drugs of addiction (Schedule 8) is privately prescribed, the prescriber must provide a written clinical rationale to the insurer that explains why:

• they are prescribing a medication that is not available through the PBS; or
• if it is available through the PBS, why they are prescribing it privately.

The insurer may request a medication review to assess the clinical appropriateness of the private prescription. The insurer should pay a reasonable private rate.

Note: In the workers compensation system, high risk medications prescribed using a private prescription within the first month from date of injury do not require clinical rationale.

3.   Medication review

Harms and risks can occur with ongoing use of high risk medications. A medication review can be requested by an insurer to provide an independent assessment of the overall medication prescribed.

The medication review is conducted by a registered pharmacist or medical practitioner with the person and their doctor.

The review should result in a medication plan informed by evidence and clinical best practice guidelines.

A medication review is indicated when there is:

• a repeat prescription for high risk medications
• multiple opioid medications
• a combination of high risk medications (e.g.. opioids, benzodiazepines, sleep medications and antidepressants)
• multiple prescribers (this excludes multiple practitioners within the same clinic prescribing high risk medications that are in accordance with the authority details for that medication)
• multiple pharmacies supplying the injured person with high risk medications
• injectable narcotics or medicinal cannabis prescribed
• high risk medications used for over 2 weeks
• high risk medications supplied in doses that exceed the manufacturer’s recommended maximum therapeutic dose
• a transition to the GP following discharge from hospital (e.g., post surgery or if discharged with high risk medications)
• comorbidities such as psychiatric disorders, cardiovascular disease, respiratory disease, sleep apnoea
• history of drug dependence or addiction
• a risk of self-harm
• concern about misuse of medications (injecting, supplying to others).

Following a medication review, a practitioner suspected of overprescribing high risk medications should be referred by the insurer to the Health Care Complaints Commission or relevant professional council. SIRA should be advised by the insurer of that notification with the reasons for the complaint.

4.   Standardised pharmacy invoicing

Standardised invoicing will enable insurers to see the essential information about the person’s injury related medications. It will facilitate data collection and will enable preventative and proactive management of high risk medications. The invoicing requirements below are specified in the Guidelines for the Provision of Relevant Services (Health and Related Services).

Direct billing accounts

Direct billing accounts from a registered pharmacy should provide the insurer with the following information:

• a dispensary computer generated tax invoice for PBS and private (non-PBS) medications supplied for treatment of the compensable injury
• the statement of account for over the counter and equipment items supplied to the person for treatment of their compensable injury.

Where the item type is not clearly identifiable on the invoice or statement, this may be handwritten:

• OTC - over the counter
• PBS - Pharmaceutical Benefits Scheme
• PRIV - private (non-PBS) medication.

Invoice and statements

Invoice and statements must contain the following information.

Reimbursements

To claim a reimbursement, the person should request that the pharmacy provide them with:

• a dispensary computer generated tax receipt for PBS and private (non-PBS) medications supplied for treatment of their compensable injury
• a dispensary receipt or a cash register receipt for over the counter and equipment items supplied for treatment of their compensable injury.

The insurer may request further information from the person or the pharmacy provider if the invoices or receipts (for example, a cash register receipt) have insufficient detail to identify the medication or item that was supplied to the person.

Appendix 1: High risk medications

Scheduling is a national classification system that controls how medicines and poisons are made available to the public. Medicines and poisons are classified into Schedules according to the level of regulatory control over the availability of the medicine or poison required to protect public health and safety.

Schedule 8 drugs (S8 or drugs of addiction)

Schedule 8 medications are classified as drugs of dependence according to the Drugs and Poisons Controlled Substances Act 1981. The misuse of S8 medications can lead to physical and psychological dependence and significant harm. To mitigate this risk, their supply and use are controlled and restricted.

These include opioids to treat pain and some benzodiazepines used to treat anxiety and sleep disorders.

A full table of Schedule 8 drugs is available on the NSW Health website.

Schedule 4 medications (S4)

Schedule 4 medications are prescription only medications.

These includes benzodiazepines (predominantly used to treat sleep disorders and anxiety), sleeping tablets, codeine (in combination with paracetamol or ibuprofen), and dextropropoxyphene.

Z drugs (S4)

Zolpidem and zopiclone are included under sedatives (hypnotics for the treatment of insomnia). They are considered high risk when combined with other high risk medications and are meant to be used on a short-term basis for the treatment of insomnia. They are often used on a long-term basis, referred to as 'off-label' and treatment is no longer evidence based.

Opiate replacement therapy / medication-assisted treatment of opioid dependence (MATOD) (S8)

MATOD medications are medications prescribed by doctors to assist people addicted to opioid medications.

Injectable narcotics (S8)

Injectable narcotics are opioid medications that are injected into the body. They are the most high risk opioids due to delivery direct into the blood stream.

Medicinal cannabis (S4 or S8 depending on concentration)

Medicinal cannabis are cannabinoid-based medications used for pain management as well as for managing anxiety and sleep disorders.